What is Thalamic Pain Syndrome?
Thalamic Pain Syndrome
Thalamic pain syndrome is a painful condition that can develop after a stroke affects the thalamus, a deep part of the brain. It is a type of central nerve pain, meaning it comes from the brain itself rather than from an injury to the body. It is often linked with changes in temperature sensation, and people with it can feel intense pain from things that normally aren’t painful (1). It was once called Dejerine-Roussy syndrome and is now more often called central post-stroke pain.
Call 911 right away for any new stroke symptoms, such as sudden face drooping, arm or leg weakness, numbness, trouble speaking, vision loss, severe dizziness or a sudden severe headache. Fast treatment matters.
How Common Is Thalamic Pain Syndrome?
An estimated 56,000 new cases of central post-stroke pain occur each year in the U.S., and about 20% to 33% of them follow a stroke in the thalamus. Even though it is common, it can be hard to diagnose, because the pain may begin anywhere from weeks to months, or occasionally years, after the stroke. Many people develop pain within the first few months (1).
What Are the Symptoms of Thalamic Pain Syndrome?
Normally, the brain treats something as painful when it could damage the body. Light touch and mild temperature changes shouldn’t hurt, but in thalamic pain syndrome they can. Pain from things that normally aren’t painful is called allodynia. Pain that is stronger than expected from something that is mildly painful is called hyperalgesia. Both are common in thalamic pain syndrome (1). The condition is also linked with mood changes, fatigue, sleep problems, a tendency to focus on and fear the pain, and changes in thinking. Depending on which parts of the brain the stroke affected, strength, facial and eye movements, balance and speech may also be affected.
What Happens in the Brain With Thalamic Pain Syndrome?
The thalamus is a deep brain structure that acts as a relay station for almost all sensory information coming into the brain. We are constantly taking in sensory information from the world around us. It travels through the nerves of the body to the spinal cord and brain, and on its way, it passes through the thalamus, which sends it to the right areas of the cortex to be interpreted.
In thalamic pain syndrome, this relay process is damaged, usually by a stroke in that area. The stroke may be ischemic, caused by a blocked blood vessel, or hemorrhagic, caused by a burst blood vessel. Either way, the parts of the brain that depend on that blood vessel can be damaged or die.
You have a thalamus on each side of the brain. Damage to one side affects sensation on the opposite side of the body (1). So if the left thalamus is damaged, sensory information from the right side of the body may be misread, and normal sensations can be felt as pain.
How Is Thalamic Pain Syndrome Diagnosed?
Thalamic pain syndrome is diagnosed by a medical provider based on your history and a physical and neurological exam. Typically, the pain is in the part of the body served by the area of the brain that was damaged, it begins after the stroke, imaging such as MRI shows a stroke in the right location, and the pain can’t be explained by another cause.
How Is Thalamic Pain Syndrome Usually Treated?
Thalamic pain syndrome is usually treated by a physician with medications for nerve pain, such as certain antidepressants and anti-seizure medications. Common pain relievers often don’t work well for this type of pain. Other options can include physical therapy, cognitive behavioral therapy and, for severe cases, brain stimulation procedures (1).
The movement, thinking and other neurological problems that follow a stroke are usually treated with physical, occupational and speech therapy. These therapies are very helpful. As recovery slows, many programs shift more toward teaching people ways to work around lost abilities. Our care focuses on continuing to look for ways to improve function in the systems that remain.
How the NeuroRescue Program Can Help
Our care is designed to work alongside your physician, neurologist and stroke rehabilitation team, never in place of them. Please don’t change or stop any medication, including blood thinners or blood pressure medication, without talking with your prescriber.
One important idea in stroke recovery is called diaschisis. Nerve cells need three main things to stay healthy: glucose, oxygen and activity. They need ongoing stimulation to keep making the proteins and other parts they need to stay healthy and work well. In a stroke, nerve cells supplied by the blocked or burst blood vessel lose their supply of glucose and oxygen, and many are lost unless blood flow is restored quickly.
No one can bring back nerve cells that have been lost. But the lost cells usually aren’t the only reason for the symptoms after a stroke.
That’s where diaschisis comes in. Each nerve cell receives signals from thousands of other nerve cells, and that input helps keep it active and healthy. When nerve cells are lost in a stroke, other nerve cells they connected to, even in areas with a normal blood supply, can lose that input. Those cells may become less active, lose endurance and tire easily, even though they still get plenty of glucose and oxygen.
These weakened but still-living nerve cells need the right amount of activity. Too little activity can leave them underused, while too much can overwhelm them. But if we can find another pathway that feeds into these cells, and activate it at a level they can handle, it may help rebuild function in the affected areas.
This idea guides our approach to stroke rehabilitation. We use detailed testing to look not only at which areas are damaged, but also at which systems are still working but weakened. We look for pathways we can use to support those weakened systems, and we adjust how much and how often we stimulate them so they’re challenged without being overwhelmed. Then we choose therapies based on what your nervous system needs, with the goal of helping you recover as much function as possible.
Research suggests spinal adjustments may do more than move a joint. Studies using EEG, brain stimulation and brain imaging have found that adjustments can produce short-term changes in how the brain processes sensory and movement information, including in the prefrontal cortex and the areas that plan and control movement (2, 3, 4, 5). Researchers are still working to understand how long these changes last and how they relate to symptoms, but they help explain why we look at how your whole nervous system is working, not just your spine. One study in people with chronic stroke found that a single adjustment session increased the brain’s drive to a weakened leg muscle compared with a control, though it didn’t measure whether strength or walking improved (6).
Electrical stimulation. Gentle electrical stimulation applied through the skin, also called non-invasive neuromodulation, can stimulate the brain through the nerves of the body. It has been studied for improving movement in people with weakness on one side after a stroke (7).
Light therapy. Photobiomodulation uses low-level laser and LED light. It has been studied as a way to support nerve cell energy and function after a stroke and other blood vessel injuries (8, 9).
Transcranial magnetic stimulation. TMS uses magnetic pulses to stimulate specific areas of the brain. It has been studied for chronic pain and for restoring movement after a stroke (10, 11), and specifically for thalamic pain syndrome (12). TMS is generally safe and well tolerated. At our clinic, TMS is provided by our psychiatric mental health nurse practitioner, who will evaluate whether it may be appropriate for you.
Balance and vestibular therapy. Balance problems are very common after a stroke and raise the risk of falls, including head injuries. Reducing fall risk is a priority in our care. Vestibular therapy has been shown to help improve balance after a stroke (13).
Vision and eye movements. Vision is often affected after a stroke. People may have trouble mapping their surroundings, keeping their eyes steady on a target, following moving objects or handling busy visual environments, and some lose part of their field of vision. We use visual exercises and rehabilitation tailored to your needs, an approach supported by research (14). Certain eye movement exercises have also been studied for supporting thinking and executive function (15), and one study found improvements in brain wave activity and symptom scores after stroke (16).
Remapping the body. Mirror therapy uses a mirror image of your unaffected limb to give your brain a different picture of the affected limb during sensory and movement exercises (17). It has also been studied in a virtual reality environment (18), and we use our Virtualis system for this. Once the brain and nervous system have been addressed, physical exercise and soft tissue therapies can help, and joint manipulation and mobilization have been studied for reducing pain in chronic post-stroke pain (19). Chiropractic adjustments are used when appropriate and safe for you.
Some programs include mild hyperbaric therapy as a structured recovery option between more demanding therapy sessions. The therapies we recommend are always chosen based on your testing and exam findings.
How the NeuroRescue Program Works
Your NeuroRescue Program begins with your Discovery Day. We start with a detailed history of your condition and your life on a timeline. This helps us understand the factors that may have contributed to where you are now, and identify related conditions that may be making it harder to move forward.
We measure how your visual, vestibular and balance systems are working through computerized analysis of your eye movements, inner ear reflexes and balance under different conditions. Our testing includes videonystagmography and saccadometry to measure several types of eye movements, the video head impulse test to measure inner ear reflexes, and CAPS computerized posturography to assess your balance under different sensory conditions. We also use NeuroSensoryMotor Integration testing to evaluate hand-eye coordination and cognition, and Virtualis testing to assess dynamic eye tracking and your perception of vertical in a virtual reality environment.
We combine this with a thorough physical and neurological exam of your sensory, motor, autonomic and cognitive systems. We also review any relevant lab work, imaging and prior testing, and integrate it with our findings.
Together, this helps us understand which parts of your nervous system are working well, which are struggling, and how quickly they tire. We use that information to design your personal NeuroRescue Program, aimed at improving function in the systems that need support and helping them work together. Our testing also helps us decide when to push and when to let you rest.
Our goal is to help calm the pain signals and strengthen the systems that remain, so you can move, rest and live with more comfort.
Your Next Step
Living with pain after a stroke can be exhausting, and it can feel like no one understands what you’re going through. You don’t have to face it alone. To find out if the NeuroRescue Program is right for you, contact one of our patient care coordinators to schedule your Discovery Day.
It’s never too late to take the next step.
References
